Pamela Dawn F. Acabal Patrick Raymond F.
Atilano January 11, 2009 Hypovolemic Shock most commonly results from acute blood loss – about 20% of total volume. Without sufficient blood or fluid replacement, hypovolemic shock may lead to irreversible damage to organs and systems. What causes it Massive volume loss may result from: GI bleeding, internal or external hemorrhage, or any condition that reduces circulating intravascular volume or other body fluids. Intestinal obstruction Peritonitis Acute pancreatitis Ascites Dehydration from excessive perspiration, severe diarrhea or protracted vomiting, diabetes insipidus, diuresis, or inadequate fluid intake. Pathophysiology potentially life- threatening, hypovolemic shock stems from reduced intravascular blood volume, which leads to decreased cardiac output and inadequate tissue perfusion. The subsequent tissue anoxia prompts a shift in cellular metabolism from aerobic to anaerobic pathways. This results in an accumulation of lactic acid which produces metabolic acidosis. The road to shockville When compensatory mechanisms fail, hypovolemic shock occurs in this sequence: • decreased intravascular fluid volume • diminished venous return, which reduces preload and decreases stroke volume • reduced cardiac output • decreased mean arterial pressure • impaired tissue perfusion • decreased oxygen and nutrient delivery to cells • multisystem organ failure. What to look for the specific signs and symptoms exhibited by the patient depend on the amount of fluid loss. Estimating Fluid loss • The following assessment parameters indicate the severity of fluid loss. Minimal fluid loss Intravascular volume loss of 10% to 15% is regarded as minimal. Signs and symptoms include: • slight tachycardia • normal supine blood pressure • positive postural vital signs, including a decrease in systolic blood pressure 10 mmHg or an increase in pulse rate 20 beats/minute • increased capillary refill time
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3 seconds urine output > 30 ml/hour cool, pale skin on arms and legs anxiety
Moderate Fluid Loss Intravascular volume loss of about 25% is regarded as moderate. Signs and symptoms include: • rapid, thready pulse • supine hypotension • cool truncal skin • urine output 10 to 30 ml/hour • severe thirst • restlessness, confusion or irritability Severe Fluid Loss Intravascular volume loss of about 40% or more is regarded as severe. Signs and symptoms include: • marked tachycardia • marked hypotension • weak or absent peripheral pulses • cold, mottled, or cyanotic skin • urine output <10 ml/hour • unconsciousness What to do assess the patient for the extent of fluid loss and begin fluid replacement as ordered. Obtain a type and crossmatch for blood component therapy. ABCs and ABGs assess ABCs. If the patient experiences cardiac or respiratory arrest, start CPR. Administer supplemental oxygen as ordered. Monitor oxygen saturation and ABG studies for evidence of hypoxemia and anticipate the needs for ET intubation and mechanical ventilation should the patient’s respiratory status deteriorate. Monitor vital signs, neorologic status and cardiac rhythm continuously for changes such as cardiac arrhythmias or myocardial ischemia. Monitor hemodynamic parameters, including CVP, PAWP and cardiac output and input. Monitor intake and output closely. Administer blood component therapy as ordered; monitor serial Hb values and HCT to evaluate effects of treatment. Administer dopamine or norepinephrine I.V., as ordered, to increase cardiac contractility and renal perfusion. Watch for signs of impending coagulopathy (such as petechiae, bruising, and bleeding or oozing from gums or venipuncture sites) and report them immediately. Provide emotional support and reassurance appropriately in the wake of massive fluid losses. Prepare the patient for surgery as appropriate.